Introducing Evidence-Based Medicine as a Workplace-Based Assessment

Austin Meyer, MD, PhD, MS, MPH, MS, FAAP

2024-09-24

Overview

  1. Motivating EBM as a Workplace-Based Assessment
  2. Enhancing the Quality of Medical Students’ EBM Presentations
  3. Evaluation and Feedback for EBM Presentations

Motivating EBM was a WBA

WBAs as a Bridge Between Theory and Practice

  • Traditional classroom-based EBM teaching often fails to translate into clinical skills.
  • WBAs enable students to apply EBM in real-time, working with actual patients.
  • Integration of EBM into WBAs provides a continuous learning process, improving knowledge retention and clinical decision-making.
  • Reference: Coomarasamy & Khan (2004): What is the evidence that postgraduate teaching in evidence based medicine changes anything?

Utilizing Case-Based Learning to Apply EBM

  • Benefits:
    • Enhances critical thinking and decision-making skills.
    • Bridges the gap between theory and clinical practice.
    • Fosters teamwork and communication among learners.
  • Case-based learning significantly improves EBM knowledge and application.
  • Reference: Young T, Rohwer A, Volmink J, Clarke M. What are the effects of teaching evidence-based health care (EBHC)? Overview of systematic reviews.

Benefits of Clinical Integration of EBM through WBAs

  • Increases clinical relevance: Students apply PICO questions directly related to patient care.
  • Improves retention: WBAs reinforce the application of EBM principles in real clinical scenarios, improving retention compared to standalone methods.
  • Enhances behavior: Clinically integrated WBAs lead to better behavior change, such as literature review habits and evidence application.
  • Reference: Coomarasamy & Khan (2004): What is the evidence that postgraduate teaching in evidence based medicine changes anything?

Essential Components of EBM in WBAs

  • Problem Formulation: Students develop clinically relevant PICO questions during rounds.
  • Critical Appraisal: Students assess literature for relevance and validity directly in patient care scenarios.
  • Application: EBM findings are immediately applied to patient management, bridging theory and practice.
  • Reference: Kasai et al. (2024): Effect of a workplace-based learning program on clerkship students’ behaviors and attitudes toward evidence-based medicine practice.

Structured Feedback and Reflection in WBAs

  • Structured Feedback: Feedback on EBM presentations helps students refine their skills and improve their understanding of clinical applicability.
  • Reflection: Encouraging students to reflect on their EBM processes reinforces continuous learning and helps integrate evidence into future patient care.
  • Reference: Kasai et al. (2024): Effect of a workplace-based learning program on clerkship students’ behaviors and attitudes toward evidence-based medicine practice.

Challenges in Implementing EBM as a WBA

  • Time Constraints: Faculty often struggle to integrate EBM teaching into busy clinical schedules.
  • Varying Student (and faculty) Preparedness: Differences in prior EBM knowledge can impact the effectiveness.
  • Sustaining Long-Term Behavior Change: EBM behavior may diminish over time without continuous reinforcement.

Students’ Perspective on EBM Teaching in WBAs

  • Positive Reception: A systematic review found that students generally have a positive perception of learning EBM through practical applications.
  • Increased Engagement: WBAs make EBM more engaging as students actively formulate clinical questions and apply evidence to real patients.
  • Improved Skills: Evidence shows improved critical thinking and decision-making skills when students are assessed via WBAs that integrate EBM principles.
  • Reference: Effectiveness of Teaching Evidence-Based Medicine to Undergraduate Medical Students: A BEME Systematic Review (2024).

Enhancing the Quality of Medical Students’ EBM Presentations

Importance of Asking Answerable Questions

  • EBM Foundation: The first step in EBM is formulating clear, answerable clinical questions using the PICO framework (Patient, Intervention, Comparison, Outcome).
  • Types of Questions:
    • Background: General knowledge about a condition or intervention.
    • Foreground: Specific knowledge to inform clinical decisions (PICO format).
  • Example:
    • P: Patient with hypertension, I: Lifestyle changes, C: Medication, O: Blood pressure reduction.
  • Reference: How to Practice and Teach EBM: Asking answerable questions is a crucial skill in EBM (Chapter 1).

Teaching Strategies for Asking Better Questions

  • Role Modeling: Faculty should demonstrate the process of turning clinical uncertainty into answerable questions during rounds.
  • Interactive Methods: Group activities where students formulate and refine clinical questions with peer and mentor feedback.
  • Reference: How to Practice and Teach EBM (Chapter 1): Role modeling and interactive teaching enhance question formulation skills.

Acquiring the Best Evidence for EBM

  • Key Resources: Teach students how to efficiently use preappraised sources (e.g., Cochrane, UpToDate) for quick evidence retrieval.
  • Search Strategies: Focus on systematic and strategic search techniques (e.g., using Boolean operators, medical subject headings (MeSH)) to find relevant studies.
  • Understanding Study Hierarchy: Would prefer studies with inherently lower risk of bias.
  • Reference: How to Practice and Teach EBM (Chapter 2): Effective use of evidence sources is critical to successful EBM presentations.

Appraising Evidence: Levels of Evidence

Teaching the Evidence Search Process

  • Educational Prescriptions: Assign students clinical questions and guide them through the search process to find answers.
  • Practical Exercises: Incorporate case-based learning where students are required to locate and appraise evidence for their cases.
  • Reference: How to Practice and Teach EBM (Chapter 2): Effective teaching involves guiding students through the evidence search process.

Appraising Evidence for EBM Presentations

  • Critical Appraisal: Teach students how to evaluate the validity, relevance, and applicability of research.
  • Key Appraisal Criteria:
    • Study Design: experimental vs. observational studies.
    • Bias Assessment: How to detect selection bias, performance bias, and publication bias.
    • Strength of Evidence: Use established tools like GRADE to assess evidence quality.
  • Reference: How to Practice and Teach EBM (Chapter 3): Critical appraisal is essential for applying evidence effectively.

Understanding study type and its analysis

GRADE to assess risk of bias

GRADE Assessment Training from Cochrane

Enhancing Students’ Appraisal Skills

  • Group Appraisal Sessions: Encourage group discussions and collaborative appraisal to improve skills.
  • Use of Checklists: Introduce students to critical appraisal checklists (e.g., CASP, CONSORT) to structure their evaluations.
  • Reference: How to Practice and Teach EBM (Chapter 3): Collaborative appraisal improves students’ understanding and application of evidence.

CASP for critical appraisal

CASP checklists for critically appraising an article

Evaluation and Feedback for EBM Presentations

Structured Feedback in EBM Presentations

  • Pendleton’s Rules:
    • Self-Assessment: The learner reflects on their performance.
    • Positive Feedback: Supervisor provides specific, positive remarks on strengths.
    • Constructive Feedback: Areas for improvement are identified.
    • Action Plan: The learner outlines steps for improvement.
  • Benefits:
    • Promotes reflection and continuous learning.
    • Ensures feedback is balanced, constructive, and actionable.
  • Reference: Pendleton, E. J., George, C., Wallis, M., & Kogan, J. (1984). A model of feedback in clinical medical education. Medical Education, 18(6), 343–348.

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